CASE
A 33-year-old male presented to the emergency department (ED) with fever, night sweats, and chills for 1 week. OTC cold remedies had not provided relief. His current symptoms were not associated with cough, chest pain, or shortness of breath, and the patient denied any weight loss, loss of appetite, or recent travel. He denied having any sick contacts. He was from Jamaica and had been living in the United States for more than 10 years. He had no history of tobacco use but admitted to occasional marijuana use and reported limited alcohol intake. The family history was significant for diabetes on the father's side and a treated tuberculosis infection in the maternal grandmother. The patient said that he had undergone purified protein derivative (PPD) skin testing 3 years ago, and the result was negative.
Examination The initial evaluation in the ED revealed a temperature of 100.9°F; pulse, 97 beats per minute; respirations, 18 breaths per minute unlabored; and BP, 158/81 mm Hg. Oxygen saturation was 96% on room air (by pulse oximetry). Physical examination demonstrated a well-developed, wellnourished male of medium build. The head and neck examination was without abnormalities. Heart sounds S1 and S2 were appreciated, along with regular rate and rhythm. The abdomen was soft and scaphoid, with positive bowel sounds in all four quadrants. The chest examination revealed unequal breath sounds with the right side diminished. Further maneuvers elicited dullness on percussion on the right side.
Testing Laboratory tests included a WBC count, which was normal but significant for monocytosis on the differential. Results of an electrolyte panel and tests for renal and liver function were within normal ranges. A rapid HIV test was negative. An ECG showed normal sinus rhythm and a heart rate of 59 beats per minute; no ST–T changes were observed, and the axis was normal.
Chest radiography demonstrated a right pleural effusion, most likely loculated (Figure 1). The radiography finding was confirmed by CT, which showed a relatively large right pleural effusion, thickened pleura, and partial loculation of the fluid (Figure 2). What diagnosis do these images suggest, and what should be the next steps?